1. The main function of the surgical anesthesia system
The surgical anesthesia system can better and more accurately record and manage the clinical information of surgery and anesthesia, and improve the work efficiency of doctors and anesthesiologists. It is mainly used for the application, approval and arrangement of patients' surgery and anesthesia, accurately records the patient's medical orders during the operation, intraoperative expenses and other information, and tracks vital signs and other monitoring data, such as heart rate, blood pressure, blood oxygen saturation information , and the entry of postoperative doctor's orders. The arrangement of hospital operation and anesthesia is a complicated process, and the operation anesthesia system can effectively ensure that the hospital operation is carried out reasonably, effectively and safely.
2. Departments involved in surgical anesthesia
1. The department where the patient is located: before the operation, the doctor will issue an operation application and provide the operating doctor.
2. Chief surgeon's department: The patient's chief surgeon may not necessarily be the patient's attending doctor, but may be a doctor called from other departments.
3. Pharmacy department: provide medicines needed for surgical anesthesia. (Some hospitals have operating room pharmacies, and surgical medicines and health materials are directly provided by the operating room pharmacies).
4. Hygienic material department: provide hygienic materials required for surgical anesthesia.
5. Blood Bank: Provide blood needed by surgical patients.
6. Inspection department: The inspection and inspection report of the patient can be extracted during the operation.
7. Operating room: provide the place for the operation and the nurses who perform the operation, arrange to prepare the operation room, and some hospital operation nurses are arranged from the clinical department.
8. Department of Anesthesiology: mainly responsible for preoperative visits, anesthesia for patients during surgery, preparation and treatment before and after anesthesia, patient monitoring and treatment, first aid recovery, pain treatment, etc.
9. Anesthesia recovery room: The anesthesia recovery room is one of the important components of the anesthesiology department, and its main task is to ensure the safety of patients during the anesthesia recovery period. The recovery period of general anesthesia has the same risks as the induction period, and patients may experience changes in breathing, circulation, nervous system, metabolism, etc. at any time during this period. In order to enable patients to go through the operation period more safely and effectively, prevent postoperative complications, and achieve the goal of early and comprehensive recovery, it is necessary to implement routine post-anesthesia monitoring for all patients undergoing general anesthesia and regional anesthesia.
10. Nursing department: do a good job of patient handover records and postoperative signs records (see the specific regulations of the hospital).
11. Toll room: collect the operation fee of the operation patient.
3. Personnel and work content involved in surgical anesthesia
1. Chief surgeon: The chief surgeon is the doctor who is mainly responsible for performing the operation.
A. Formulate the operation plan
B. Issue the operation application form
C. Perform the operation
D. Postoperative visit
2. Assistant doctor: Assistant doctor is to assist the chief surgeon in his work.
A. Issue a checklist;
B. Issue a preoperative doctor's order;
C. Communicate with the surgeon at any time about the patient's condition; D.
Communicate with the patient to understand the patient's own condition;
, Let the patient sign the surgical consent form.
F. Provide professional, patient, and detailed instructions to the operator on the preparations and related precautions during the operation; G.
Postoperative visits to understand the recovery situation, provide professional advice, and guide postoperative rehabilitation.
3. Anesthesiologist: The anesthesiologist should treat the medical problems of the patient during the perioperative period (during the operation, before and after the operation).
The anesthesiologist judges the condition before the operation, considers individual differences according to the patient's physical condition, and formulates a treatment plan based on this, and uses advanced instruments to monitor the patient's vital functions during the operation.
Contents of preoperative visit: Before anesthesia, patients should be visited before operation, including reading medical records, understanding the overall situation of the patient, emphasizing on previous operation history, anesthesia history and preoperative preparation, and making necessary examinations. At the same time, understand the patient's concerns, opinions and requirements about the operation and anesthesia, and make necessary explanations. At the same time, the possible risks and complications of anesthesia should be explained to the patient's family. According to the degree of cooperation of the patient and the method of operation, appropriate anesthesia drugs and methods are selected, and supplementary opinions on preoperative preparations are provided when necessary.
A. Visit before operation, and decide together with the doctor in charge whether the patient can bear the surgical anesthesia;
B. Decide which kind of anesthesia and monitoring measures to use;
C. Perform anesthesia on the patient;
D. Do a good job of monitoring the surgical anesthesia process, including circulation , Continuous monitoring of breathing, water electrolyte, body temperature and other functions;
E. Responsible for the doctor's orders of patients in the recovery room, and determine the admission and discharge of patients.
4. Assistant anesthetist:
A. Assist the main anesthetist in the work;
B. Fill in the anesthesia record sheet carefully and timely, and record blood pressure, pulse, respiration, and oxygen saturation every 5 minutes during the operation. If necessary, monitor the electrocardiogram, central venous pressure, urine output, body temperature, end-tidal carbon dioxide, blood gas analysis, etc., and record it every 30 minutes. If the condition is unstable, it should be monitored and recorded repeatedly. During the operation, the medication during anesthesia, blood transfusion volume, body fluid loss, main surgical steps and related complications were recorded in detail.
C. According to different conditions and operations, do a good job in various treatments after anesthesia, including continuous monitoring of patients, preventing complications, timely handling of accidents, assisting clinical departments to treat complications, so that patients can recover as soon as possible.
5. Hand washing nurse: directly participate in the operation and cooperate with the doctor to complete the whole process of the operation. Its scope of work is limited to the sterile area, such as transferring instruments, materials and various objects. Because they work in a sterile area, they must wash their hands and arms, wear sterile surgical gowns and sterile gloves, so they are also called hand washing nurses, sterilization nurses or surgical nurses.
A. One day before the operation, understand what kind of operation the patient will perform and the doctor's special requirements for the operation, be familiar with the local anatomy and operation steps, and cooperate with the operator to complete the operation.
B. Wash your hands 15 minutes in advance, check the various supplies needed for the operation, check the number of gauze, gauze pads, instruments, and stitches with the itinerant nurse before the operation, assist the operator in disinfecting the patient's skin, and lay out the treatment towel, Strictly abide by the aseptic operation rules, pay attention to the cleanliness and dryness of the operating table, and replace it immediately if it is contaminated.
C. Concentrate on observing the progress of the operation, and transfer the instruments quickly and accurately. The used instruments should be dried and restored immediately, and should not be placed on the patient. The surgical specimens should be sent to pathological examination.
D. Before closing the body cavity, the doctors and nurses involved in the operation count gauze, gauze pads, instruments, and needles together. The body cavity can only be closed when the number of operations completely matches.
E. After the operation, clean the general instruments and fine instruments, dry them and put them back to their original places.
F. There is no substitution during the whole operation.
6. Itinerant nurses: Although they do not directly participate in the cooperation of surgical operations, they are assigned in a fixed operating room to cooperate with hand-washing nurses, operators, assistants and anesthesiologists to complete surgical tasks. The scope of indirect cooperation is outside the sterile area, among patients, surgical personnel, anesthesiologists and other personnel, so it is called itinerant nurse.
A. Prepare the items in the operating room;
B. Take the patient into the operating room;
C. Assist in infusion and position anesthesia;
D. Assist the surgical staff in disinfecting the skin of the surgical area and assisting the surgical staff in wearing surgical gowns; check with the surgical nurse Surgical instruments and items, etc. and record.
E. Arrange the patient's surgical position and fully expose the surgical site. If medication-type blood transfusion is required during the operation, the checking system must be strictly implemented.
F. Closely observe the progress of the operation and supply needed items on the table in time; execute oral doctor's orders and record them; assist the anesthetist in observing the condition and cooperate with the rescue; before closing the body cavity, check the equipment and items with the surgical nurse again and record them.
G. Assist in bandaging the wound and remove the blood around the wound; count the items brought with you, and send the patient back to the ward with the anesthesiologist and return the items; organize the items in the operating room, and then routinely disinfect them. If the operation is severe infection or specific Infected ones should be treated specially.
H. Pay attention to the cleanliness of the room at all times, adjust the lights and room temperature appropriately, and wipe the doctor's sweat; add items needed for the operation in time, and record them for future reference.
I. Organize nursing records.
7. Nurse in the recovery room
A. Ask the anesthesiologist about the patient's intraoperative situation;
B. Properly place the infusion device, various drainage tubes, and negative pressure devices to maintain the smooth flow of intravenous infusion and blood transfusion, and ensure the smooth progress of blood transfusion; C.
Indwell Urinary catheterization should strengthen the catheter, remove the urine in the bag in time and record the urine volume;
D. Find and deal with respiratory problems in time;
E. Do a good job of monitoring vital signs, electrocardiogram, and blood oxygen saturation, and timely symptomatic treatment;
F. Observation Patient's awareness, pupil size and light reaction, limb movement, postoperative bleeding, etc. of craniocerebral trauma patients; G.
Safely and adequately relieve postoperative pain;
H. Help the patient to perform limb movement and deep breathing, if necessary Artificial ventilator assisted breathing;
I. Observe the consciousness, limb activity, muscle tension recovery and skin color of the patient under general anesthesia, measure blood pressure, pulse, respiration, and blood oxygen saturation for 5 to 10 minutes as appropriate, and make records.
J. Recording of events in the resuscitation room and rescue medical records;
Note: There is no strict division of labor between chief surgeon and assistant doctor, chief anesthetist and auxiliary anesthetist, which mainly depends on the specific regulations of the hospital. If there is no assistant doctor during the operation, all the work of the assistant doctor will be done by the chief surgeon. If there is no assistant anesthetist during the operation, the main anesthetist will also do the job of the assistant anesthetist.
4. The relationship between the characters in the operation
In an operation, the surgeon, anesthesiologist, and surgical nurse are all in a relationship of mutual assistance and cooperation.
Surgeon's order for surgery
The surgical nurse arranges the operation according to the operation doctor's order
The anesthesiologist conducts a pre-visit to the patient according to the surgical doctor's order, and feeds back the results of the visit to the surgeon
In the operation, the three parties must fully cooperate in order to successfully perform the operation. The anesthesiologist is the prerequisite for a successful operation, the surgeon is the key to a successful operation, and the surgical nurse is the guarantee for a successful operation.
Surgeons treat diseases, and anesthesiologists protect lives. Anesthesia and surgery are actually twin brothers, and neither will work without the other. The general process of preparing for anesthesia includes anesthesia machines, monitors, drugs, liquids, and then the establishment of pathways. Two pathways are very important to us. One is intravenous access, and the other is endotracheal intubation. We need to ensure the patient’s oxygen balance. It can regulate the patient's life indicators, his depth of anesthesia, consciousness, blood pressure, respiration, pulse, body temperature, acid-base balance, and a series of processes of electrolytes. The operation and anesthesia need to cooperate closely. How long the operation lasts depends on how long the anesthesia should be maintained. For a long time, first of all, the anesthesia has to be anesthetized before the operation is completed. After the second operation, it is not allowed to stay awake for a long time. Therefore, the surgeon should closely cooperate with the anesthesiologist on the operation time and operation steps, and the anesthesiologist should decide the drugs according to the operation steps.
5. Documents involved in surgical anesthesia
1. Operation application form: The operation notice is a written notice issued by the surgeon in the operation department for the operation patient. Within a limited time, (usually one day in advance) sent to the operating room for preoperative preparation. The operation notice is the link between the operation department and the operating room, and all work in the operating room is based on the operation notice.
It is a guide for the preparation of preoperative surgical supplies.
The operation is based on the operation notice. It
is the basis for query and statistical work
. Operation, operation time, blood preparation, remarks (generally special equipment required during the operation)
2. Consent for surgery: Before the operation, the doctor must explain to the patient or family members the possible dangers during or after the operation, and list a document of possible dangers, and ask the patient or family members to sign and agree before performing the operation. Different hospitals use different names for the operation consent form, including the operation notice, operation agreement, operation informed consent, operation voluntary letter, preoperative conversation record, etc., but their content, nature and function are consistent.
The contents of the operation consent form include: ⑴ basic information of the patient; ⑵ preoperative diagnosis; ⑶ planned operation plan; ⑷ possible complications and accidents during and after the operation; (5) surgical risks;
3. Nursing record sheet: Nursing record sheet includes nursing preoperative visit sheet, intraoperative record sheet and postoperative visit sheet. Each hospital may be different. In some hospitals, the preoperative visit form is accompanied with the medical records, while the postoperative visit form is kept by the hospital itself, which mainly depends on the specific regulations of the hospital.
3.1.1 Preoperative visit content:
A. The day before the operation, the itinerant nurse will visit the patient in the ward to understand the patient's condition;
B. Psychological care, relieve the patient's fear and tension, and make the patient undergo the operation in the best condition.
C. Propagate and teach the preparations before entering the operating room, so that patients can consciously cooperate and make preparations before the operation. Ensure the safety of the operation;
D. The cooperation of anesthesia and postoperative attention points, so that the patient can better cooperate with the implementation of anesthesia and go through the perioperative period smoothly;
3.1.2 Contents of the preoperative visit list:
A. The patient’s basic information, such as name, gender, age, etc.;
B. The patient’s planned operation;
C. The patient’s vital signs;
D. The patient’s medical history, including current illness history and past history , history of surgery;
E, the patient’s living habits and the patient’s attitude towards surgery;
F, the contents of the visit introduced to the patient;
Note: after the interview, discuss with other nurses and formulate a nursing plan based on the information obtained from the patient .
3.2. Intraoperative records
1. Basic information: department, name, gender, age, ward, bed number, hospitalization number;
2. Preoperative diagnosis, operation name, drug allergy history, weight, operating room, sterile bag monitoring, specimens Send pathology, operation start time, operation end time, others, device dressing name, quantity (there are two columns before operation and after operation), device nurse’s signature (in order to ensure that the operation nursing record sheet is completed in time, the preoperative device nurse must personally 3.
Nursing conditions during the operation: including the time of entering the room, operation position, intraoperative blood transfusion, infusion, urine volume, drainage tube, and the use of special instruments (performed by the itinerant nurse), such as: electric hemostat usage of.
4. Matters that need to be handed over to other nurses, such as the observation and handover of newborns delivered by cesarean section, the time of leaving the room, the blood pressure, pulse, consciousness, skin and other conditions when leaving the room. The blood type, composition and volume should be recorded for blood transfusion, the color, nature and volume of urine should be recorded, the number and location of drainage tubes, and the condition of drainage fluid should be recorded.
5. Instruction card and identification The sterilization instruction card of the sterile package used in the operation and the identification of the medical device implanted in the body shall be pasted on the back of the operation record after inspection, and the names of the sterile package and the device shall be marked respectively.
3.3.1 Contents of postoperative visit:
A. Inform the patient of the success of the operation and relieve the patient’s concerns;
B. Find out whether the patient has abnormalities after the operation;
C. Eat a reasonable diet after the operation;
D. Explain the discomfort that may occur in the short term after the operation, Inform the method of self-regulation;
E. Postoperative exercise;
3.3.2 Contents of the postoperative visit list:
A. Basic information of the patient, such as name, gender, age, etc.;
B. The vital signs of the patient;
C. Whether the patient has Abnormal;
D. Postoperative physical condition and recovery of the patient;
4. Anesthesia record sheet:Complete anesthesia records include pre-anesthesia visits, anesthesia consent forms, anesthesia records during surgery, and post-anesthesia (post-anesthesia recovery room, post-operative pain treatment). Pre-anesthesia visits are in the form of "pre-anesthesia visit record sheet", anesthesia records during operation and post-anesthesia recovery room records are in the form of "anesthesia record sheet", and postoperative analgesia is in the form of "post-operative pain treatment record sheet", which is summarized into one A complete copy of the data is saved.
4.1 Pre-anesthesia visit record The
pre-anesthesia visit record generally adopts the form of "pre-anesthesia visit record", which is a separate page and is kept together with the patient's medical records.
Content:
1. General items
⑴ patient's name, gender, age.
⑵Department, ward, bed number, inpatient number.
2. Clinical diagnosis: including the clinical diagnosis of diseases that require surgery and the clinical diagnosis of other diseases that coexist.
3. Patient's vital organ function and disease status: mainly includes the patient's basic vital signs, cardiovascular system, lung, liver, kidney and other vital organ system functions, as well as coexisting diseases.
4. Classification of the patient's physical condition: generally according to the American Society of Anesthesiologists (ASA) physical classification I, II, III, IV, and V, and E is added for emergency.
5. Surgical anesthesia risk assessment: Anesthesia surgery risks are generally divided into five categories according to the patient's general condition and the type of surgery: generally low risk, certain risk, high risk, very high risk, critical condition near death, and abnormal risk. kind.
6. The proposed anesthesia method and auxiliary measures: the anesthesia methods are divided into spinal anesthesia, nerve block anesthesia, and general anesthesia. Anesthesia auxiliary measures include monitoring methods, controlled hypotension, and artificial hypothermia.
Intraspinal anesthesia: Inject local anesthetics into different spaces in the spinal canal. The drugs act on the spinal nerve roots, temporarily block the conduction of the spinal nerves, and cause anesthesia in the corresponding areas innervated by it, which is called intraspinal anesthesia. Neuraxial anesthesia includes subarachnoid block and epidural space.
Nerve block anesthesia: A local anesthetic is injected near a peripheral nerve trunk to anesthetize the area innervated by the nerve by blocking the conduction of nerve impulses.
Controlled hypotension: refers to artificially lowering the mean arterial pressure to a certain level during surgery under general anesthesia while ensuring the oxygen supply to vital organs, so that the blood loss in the surgical field decreases in parallel with the decrease in blood pressure, and makes the The surgical field is clear, reducing accidental injury to nerves and blood vessels, facilitating surgical operations, improving surgical accuracy, and shortening surgical time.
7. Other situations that need to be explained: special explanations are required for situations that may lead to complications of anesthesia for the patient or may affect the safety of the patient.
8. Signature of visiting anesthesiologist
9. Visiting time
4.2 Anesthesia consent form
The anesthesia consent form indicates that the patient or the patient's family members are aware of the anesthesia medical situation before anesthesia, and whether they are willing to bear the risk of anesthesia. The anesthesia consent form is generally a separate page, which is kept in the patient's medical record.
Contents of anesthesia consent form
1. General items
⑴ patient's name, gender, age.
⑵Department, ward, bed number, inpatient number.
2. Preoperative diagnosis: including the diagnosis of diseases that require surgical treatment and the diagnosis of other coexisting diseases.
3. The proposed anesthesia method and auxiliary measures.
4. The patient or patient's family members' knowledge of the anesthesia method.
5. Possible complications of the proposed anesthesia method and auxiliary measures.
6. Dangers of anesthesia or therapeutic drugs used during anesthesia procedures.
7. Special circumstances that may arise during the operation are a threat to the patient's life.
8. Diseases that may be induced during anesthesia surgery or exacerbate existing concurrent diseases.
9. Failure of the planned anesthesia method requires a change in the anesthesia method.
10. Self-paid drugs or non-medical insurance drugs may be required during anesthesia.
11. Patients may be admitted to the intensive care unit (ICU) after surgery.
12. Ask for postoperative pain management.
13. Other surprises.
14. Attitudes of patients or their families to the risks of anesthesia.
15. Signature of the talking anesthetist
16. talk time
17．The name of the person who signed the anesthesia consent form and the relationship with the patient.
4.3 Anesthesia record sheet
Front content of the anesthesia record sheet
1. General items
⑴ patient's name, sex, age, weight, height.
⑵ Ward, bed number, hospitalization number, date of anesthesia, single page number of anesthesia record.
(3) Diagnosis before and after the operation, the name of the operation to be performed and the operation to be performed.
⑷ Medication before anesthesia: drug name, dosage, route of administration, time.
⑸Basic vital signs of the patient before anesthesia: respiration, heartbeat, blood pressure, body temperature
⑹The name of the physician who performed the operation and anesthesia, the name of the hand washing nurse and the visiting nurse.
⑺ Special conditions: diseases that may endanger the safety of patients during the perianesthesia period, such as hypertension, coronary heart disease, severe allergies, blood diseases, tension pneumothorax, myasthenia gravis, etc.
2. Anesthesia process
(1) Anesthesia method: record the anesthesia method implemented.
(2) Respiratory management: record the patient's spontaneous respiration or artificial ventilation during the anesthesia process, indicate the oxygen inhalation mode during spontaneous respiration, and indicate the artificial ventilation mode, breathing circuit used, and respiratory monitoring indicators during artificial respiration.
⑶ Neuraxial anesthesia Record the patient's position, puncture gap, puncture needle type and slope orientation, puncture method (frontal entry, side entry), catheter insertion direction, depth of the epidural catheter in the epidural space, and anesthesia plane during spinal canal anesthesia.
(4) Endotracheal intubation: record the route of intubation (oral, nasal cavity, tracheostomy), catheter position (intratracheal, endobronchial), method (photopic vision, blind detection, bronchoscopy), catheter size, Induction method (awake, superficial anesthesia, general anesthesia), process.
Puncture: A diagnosis and treatment technique in which a puncture needle is inserted into a body cavity to extract secretions for laboratory tests, gas or contrast agent is injected into the body cavity for contrast examination, or drugs are injected into the body cavity.
⑸ Nerve block: puncture route and method.
⑹ Anesthesia drugs: drug name, dose, route of administration, and time of local anesthetics, general anesthetics, muscle relaxants, anesthesia auxiliary drugs, etc.
⑺ Anesthesia start and end time.
(8) Record the event content and the start and end time of the event.
3. Operation process
(1) Patient position: record the patient's position during the operation, and record any temporary changes in the position during the operation.
⑵Main surgical steps: briefly record the important surgical steps in the remarks column in chronological order.
(3) Important situations that endanger the safety of patients during the operation.
⑷ Operation start and end time
4. Monitoring during anesthesia
(1) Monitoring indicators during anesthesia: During anesthesia, it is mainly to monitor the patient's vital signs, internal environment and depth of anesthesia. Common monitoring methods include Bp, P, R, T, SpO2, CVP, CO, PETCO2, BIS, urine output, urine specific gravity, blood gas analysis, etc. When the condition is stable, the basic vital signs Bp, P, and R should be recorded every 5-10 minutes. Record at any time when changes occur, and other monitoring results should be recorded at any time. (Note: BP: blood pressure; T: time; SpO2: blood oxygen saturation; CVP: central venous pressure; CO: PETCO2: end-tidal carbon dioxide partial pressure
) Records, the abscissa is time, and the ordinate is monitoring indicators (indicated by symbols). SBp and DBp are represented by ∨ and ∧, P is represented by ·, R is represented by ○, nasopharyngeal temperature is represented by △, rectal temperature is represented by ×, and blood temperature is represented by ▲. Other monitoring indicators directly record the monitoring value.
(SBP: systolic blood pressure)
⑶ Monitor and record the amount of blood loss and fluid loss during the operation.
5. Possible intraoperative conditions: Vomiting, laryngeal edema, laryngospasm, bronchospasm, myocardial ischemia, pulmonary edema, hypoxia, fever, etc. during the operation. Time of occurrence and hours, treatment or rescue measures should be indicated.
5. Treatment during anesthesia:
1 Intraoperative fluid therapy: The type, quantity, route and time of use of the fluid should be recorded in time.
⑵ Intraoperative blood product treatment: For patients who need to use blood products during surgery, record the type, quantity, route and time of blood product in time.
(3) The use of other therapeutic drugs during the operation: When using vasoactive drugs, hemostatic drugs, anti-emetic and other drugs during the operation, the drug name, dosage, route of use, and time of use should be recorded on time.
7. Anesthesia recovery: Conditional hospital anesthesia recovery is generally completed in the anesthesia recovery room. Anesthesia recovery room records have the same requirements as operating room anesthesia records. For patients under general anesthesia, the recovery time of gag reflex and cough reflex, time of tracheal extubation, and extubation process should be recorded. The plane of anesthesia was recorded at the end of the neuraxial anesthesia operation.
Contents on the top page of the anesthesia record sheet
1. Medical history and physical examination summary
(1) Medical history: including present illness history, past history, anesthesia history, drug allergy history, etc.
(2) Physical examination: positive and important negative physical examination results of the patient, focusing on the physical examination results related to anesthesia, such as cardiopulmonary conditions, spine conditions, etc.
2. Preoperative main laboratory tests and inspection results
⑴ three routine results.
⑵ Liver function, kidney function, blood electrolytes, blood sugar results.
(3) PT and APTT results. (Note: PT: prothrombin time; APTT: partially activated prothrombin time)
⑷ ECG results.
⑸ Results of chest X-ray or chest X-ray.
⑹ Lung function
⑺ Other test results
3. Anesthesia summary: Anesthesia summary should generally include anesthesia risk assessment before anesthesia, implementation of anesthesia methods and reasons for selection, anesthesia induction, anesthesia maintenance, anesthesia recovery process, patient's vital signs, internal environment and anesthesia depth changes during anesthesia, and main treatment process , Evaluation of anesthesia effect, advantages and disadvantages of anesthesia.
4. Follow-up after anesthesia: mainly record whether there are any complications related to anesthesia after the operation, if there are complications, record the treatment process and prognosis, and whether there are sequelae left.
Postoperative Pain Treatment Record Sheet
A single dose of postoperative analgesia is generally recorded on the anesthesia record sheet or in the course of disease record in accordance with the requirements of treatment medication. If patient-controlled analgesia (PCA) is used to treat postoperative pain, it should generally be in the form of a "postoperative pain treatment record sheet", which should be kept on a separate page in the medical record.
Patient-controlled analgesia (PCA): It is an analgesic method in which analgesic drugs are given continuously under computer control. Patients can control the timing and dosage of analgesic drugs according to their own conditions. It is an ideal postoperative analgesic method.
Contents of Postoperative Pain Treatment Record Sheet
1. General items
⑴ patient's name, gender, age.
⑵Department, ward, bed number, inpatient number.
2. clinical diagnosis.
3. Anesthesia method.
4. Perform surgery.
5. Postoperative Pain Treatment
6. Pain treatment start time and end time.
7. The name, dose, concentration, method of use, and name of the person who prepared the drug used for pain treatment.
8. Pain treatment effect: VAS is generally used to record the analgesic effect.
9. Changes in the types, doses, and routes of administration of drugs in analgesic therapy.
10. Side effects during pain treatment.
11. Name of anesthesiologist for pain treatment observation.
4.5 Postoperative follow-up list
Routinely visit 3 days after anesthesia, write down the visit time, and observe the nervous, respiratory, circulatory, digestive and urinary systems item by item. If complications are found, follow-up should be continued, relevant information should be recorded, and the condition should be analyzed and treated together with the surgeon until the patient is cured. Those with severe complications should report to the superior physician or department director of the anesthesiology department. Follow-up should be carried out in a focused manner according to the anesthesia method, type of operation, and the patient's operating conditions, and detailed records should be made, with special emphasis on the timing of complications. , duration, measures and effects, etc. should be recorded in detail.
Contents:
(1) General anesthesia
① Complications after tracheal intubation, check for any damage to the nose, teeth, oral cavity and throat. With or without hoarseness, sore throat, laryngeal edema, pharyngitis, vocal cord paralysis, subcutaneous emphysema, mediastinal emphysema, cough, sputum blockage, etc.
②Thoracotomy can be used to find out whether there is atelectasis, secondary pneumonia, tension pneumothorax, etc., and the situation of chest drainage must also be recorded.
(2) Intraspinal anesthesia
①Record the time when the anesthesia effect subsides, and whether there is paresthesia. In case of abnormal touch, pain, temperature, vibration, or body position, record it as "hyperesthesia" for those who strengthen it, and "hypoesthesia" for those who weaken it, and record the occurrence time, duration, scope and treatment effect.
② Find out whether there is redness, swelling, tenderness or other signs of infection at the puncture point.
③Lower limb activity and muscle strength, pay attention to whether there is cauda equina syndrome.
④Headache: record the location of headache, onset time, duration, relationship between body location and headache, whether there is concurrent nausea and vomiting, neck stiffness, dizziness, auditory and visual conditions, and diplopia. If there is persistent headache, neck stiffness and vomiting after spinal anesthesia, it indicates meningeal irritation and should be closely followed up.
⑤ With or without urine retention. If catheterization is performed, the time and frequency should be recorded, and whether indwelling catheterization is necessary.
(3) Cervical plexus and brachial plexus block
①Record the time when the anesthesia effect subsides and whether there is paresthesia.
② Whether the breathing is normal, whether there is chest tightness and duration, and whether the development is normal.
③The activity of the upper arm.
④ In terms of circulatory system, no matter what kind of anesthesia follow-up, inspection and observation should be carried out. Relevant conditions such as hypotension, bradycardia, persistent hypertension or tachycardia related to vasoconstrictors should be recorded, and more attention should be paid to patients with vascular diseases before anesthesia.
⑤Signature of the anesthesiologist.
4.6 Operation record sheet
The operation record is written on the "operation record sheet" by the surgeon or the first assistant, and the superior doctor signs off. Completed within 24 hours after the operation (critically ill patients completed in time). Its contents include:
(1) Date and time of operation.
(2) Preoperative diagnosis.
(3) The name of the operation.
(4) Diagnosis after surgery.
(5) Medical personnel participating in the operation.
(6) Anesthesia method and anesthesia personnel.
(7) Medication before anesthesia and during operation.
(8) Surgical procedure. Such as patient position, skin disinfection and draping method, surgical incision, exposure method, exploration process and findings, the basis for deciding to continue the operation, the main steps of the operation, the type and number of sutures used, suture methods, drainage materials and their placement Location and number, name, nature and quantity of aspirated or extracted objects, what kind of specimens have been sent for testing, culture or pathological examination, the patient's condition and anesthesia effect during and after the operation, blood loss and blood transfusion, content and quantity of infusion wait.
(9) In case of an accident during the operation, the rescue measures and process should be recorded in detail.